Choroidal imaging biomarkers as predictors of conversion to exudative age-related macular degeneration.

PURPOSE: Predicting the progression of intermediate AMD (iAMD) to neovascular AMD (nAMD) will help to identify high-risk patients and improve treatment outcomes. The present study assessed whether choroidal OCT biomarkers could predict conversion to nAMD. METHODS: This retrospective study included patients with clinically stable iAMD who either converted to nAMD (C group) or did not convert (NC group) during one year of follow-up. OCT parameters included subfoveal choroidal thickness (SFCT), central macular thickness (CMT), Haller vascular thickness (HVT), inner choroidal thickness (ICT), and double-layer sign (DLS). RESULTS: Of 116 total eyes, there were 37 in the NC group and 79 in the C group. Baseline SFCT was significantly lower in the C group compared to the NC group (169.0 ± 63.2 µm vs. 218.0 ± 97.8 µm, p = 0.01). Baseline HVT and ICT were lower in the C group (105.2 ± 40.6 µm vs. 121.0 ± 56.6 µm, p = 0.17 and 61.9 ± 35.5 µm vs. 77.5 ± 41.7 µm, p = 0.09). HVT was decreased at all time points in the C group vs NC (p > 0.05). The ICT was reduced in the C group at each time point except at conversion time (p > 0.05). Of all eight eyes who presented DLS at baseline, 100% converted to nAMD (p < 0.001). CONCLUSION: Lower SFCT at baseline may signal conversion to nAMD within 12 months.

Bilateral multifocal chorioretinitis as the only presentation of acute West Nile virus infection: a case report.

BACKGROUND: To describe a case of bilateral multifocal chorioretinitis as the only presentation of acute West Nile virus (WNV) infection in the absence of neurological involvement. CASE PRESENTATION: A 78-year-old Italian woman was admitted to our emergency department because she noticed blurry vision in both eyes. She did not report fever, fatigue, or neurological symptoms in the last few days. Multimodal imaging showed the presence of bilateral hyperfluorescent lesions with a linear distribution, that corresponded to hypocyanescent spots on indocyanine green angiography. Antibody serology showed the presence of IgM antibodies, IgG antibodies, and ribonucleic acid (RNA) for WNV. Magnetic resonance imaging (MRI) of the brain ruled out central nervous system involvement. Three months later, the patient reported spontaneous resolution of her symptoms and remission of the chorioretinal infiltrates. CONCLUSIONS: In endemic areas, it is important to think of acute WNV infection as an explanatory etiology in cases of multifocal chorioretinitis, even without neurological involvement.

Pneumatic retinopexy for primary rhegmatogenous retinal detachment: from a clinical trial to the real-life experience.

BACKGROUND: To report real-world outcomes of patients with primary Reghmatogenous Retinal Detachment (RRD) treated with Pneumatic Retinopexy (PnR) according to the indications of the Pneumatic Retinopexy versus Vitrectomy for management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) trial. METHODS: Multicenter, retrospective study. Patients treated with PnR for RRD between 2021 and 2023 and a follow-up of at least 6 months were included. Single-procedure anatomical success, final anatomical success, complications, causes of failures, best corrected visual acuity (BCVA) after surgery, and the vision-related quality of life using the 25-Item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were reported. RESULTS: A total of 76 eyes of 76 patients were included. Mean age was 60 ± 8.1 years. Primary anatomic reattachment was achieved by 84.3% of patients and final anatomical reattachment after pars plana vitrectomy was obtained in 100% of patients. BCVA improved from 0.32 (20/40) to 0.04 (20/20) logMar (p < 0.001) at 6 months. The main cause of failure was related to the presence of additional (likely missed) retinal breaks (66.6% of cases). Also, primary PnR failure was more frequent in eyes of patients with older age, macular involvement, worse baseline BCVA, greater extent of the RRD, and increased duration from diagnosis to treatment. Overall, the mean NEI-VFQ 25 composite score was 93.9% ± 6.4 at 6 months. CONCLUSIONS: The criteria of the PIVOT trial can be applied to real-world scenarios in the decision-making process for the treatment of primary RRD, with excellent anatomical and functional outcomes.

In vivo assessment of the ocular biomechanical properties in patients with idiopathic normal pressure hydrocephalus.

PURPOSE: Idiopathic normal pressure hydrocephalus (iNPH) is associated with an increased prevalence of open-angle glaucoma, attributed to variations of the pressure gradient between intraocular and intracranial compartments at the level of the lamina cribrosa (LC). As ocular biomechanics influence the behavior of the LC, and a lower corneal hysteresis (CH) has been associated to a higher risk of glaucomatous optic nerve damage, in this study we compared ocular biomechanics of iNPH patients with healthy subjects. METHODS:  Twenty-four eyes of 24 non-shunted iNPH patients were prospectively recruited. Ocular biomechanical properties were investigated using the ocular response analyzer (Reichert Instruments) for the calculation of the CH, corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg), and corneal-compensated intraocular pressure (IOPcc). Results were compared with those of 25 eyes of 25 healthy subjects. RESULTS:  In iNPH eyes, the median CH value and interquartile range (IQR) were 9.7 mmHg (7.8-10) and 10.6 mmHg (9.3-11.3) in healthy controls (p = 0.015). No significant differences were found in IOPcc [18.1 mmHg (14.72-19.92) vs. 16.4 mmHg (13.05-19.6)], IOPg [15.4 mmHg (12.82-19.7) vs. 15.3 mmHg (12.55-17.35)], and CRF [9.65 mmHg (8.07-11.65) vs. 10.3 mmHg (9.3-11.5)] between iNPH patients and controls. CONCLUSIONS:  In iNPH patients, the CH was significantly lower compared to healthy subjects. This result suggests that ocular biomechanical properties may potentially contribute to the risk of development of glaucomatous optic nerve damage in iNPH patients.

Evaluation of peripapillary vascular flow in patients with Thyroid-Associated Ophthalmopathy (TAO) by OCT Angiography.

PURPOSE: To evaluate changes in peripapillary vascular blood flow indices (PVBFI) in patients with thyroid-associated ophthalmopathy (TAO) using OCT angiography (OCTA) technology. METHODS: Patients with TAO and control subjects matched for age and sex were included in the study. Eye examination, Clinical Activity Score (CAS) evaluation and OCTA scan analysis (Topcon ImageNet 6; DRI OCT Triton, Topcon Corporation) were performed. In particular, PVBFI of the superficial capillary plexus (SCP), deep capillary plexus (DCP), outer retina (OR) and choriocapillaris (CC) layers were obtained by OCTA and extracted from 8-bit greyscale OCT images using the ImageJ software package. RESULTS: Twenty-six patients with TAO (19 females, mean age 54.7 ± 5.2 and 7 males, mean age 51.4 ± 16.3) were compared with 26 healthy subjects (15 females, mean age 48.2 ± 14.1 and 11 males, mean age 53.1 ± 15.2). Both DCP-PVBF and CC-PVBFI were significantly reduced in TAO patients compared to control eyes (28.6 ± 2.1 vs. 29.7 ± 0.93, p = 0.002; 46.5 ± 1.72 vs. 47.2 ± 1.2, p = 0.019 respectively); on the other hand, no statistically significant differences were found in SCP-PVBFI and OR-PVBFI in TAO patients compared to healthy subjects (p > 0.05). Also, CC-PVBFI was associated with elevated values of CAS (p = 0.018) and ROC curve showed that patients with elevated CC-PVBFI were correlated with active TAO (CAS > 3) (p = 0.012). CONCLUSIONS: TAO disease may be associated with changes in DCP-PVBFI and CC-PVBFI; also, CC-PVBFI seems to correlate with disease activity.

Anterior callosal angle correlates with gait impairment and fall risk in iNPH patients.

BACKGROUND: In idiopathic normal pressure hydrocephalus (iNPH), gait and balance impairment is the most frequent symptom, and it is often associated with a higher fall risk. In a prior study, the anterior callosal angle (ACA) was validated as a reliable marker to discriminate iNPH from Alzheimer's disease and healthy controls. However, the potential correlation between the ACA with clinical symptoms and functional outcomes has not been assessed. The objective of this study is to determine the utility of the ACA in predicting gait improvement after ventriculoperitoneal (VP) shunting. METHODS: Patients with probable iNPH who underwent shunt placement at a single institution were prospectively enrolled from May 2015 to May 2019. Patients were assessed preoperatively and at 6 months postoperatively following a standard clinical and MRI protocol. Callosal angle (CA) and ACA were calculated from 3 T MRI preoperatively and at 6 months postoperatively. CA and ACA were tested for correlation with clinical scores. RESULTS: Forty-seven patients with probable INPH who completed 6-month postoperative follow-up were enrolled in the study. Baseline ACA was significantly correlated with preoperative fall risk, gait, and balance impairment assessed with Tinetti POMA scale. Additionally, baseline ACA differentiated patients who experienced improvement at Tinetti POMA scale after surgery. CONCLUSIONS: The baseline ACA is a useful neuroradiological marker to differentiate patients by fall risk and has significant correlation with the improvement in gait and balance impairment following surgery. This study demonstrated that the ACA may be a complementary tool to the CA in predicting shunt responsiveness in iNPH.

Viscoelastics Enable Dissection of Anterior Closed Funnels in Proliferative Vitreoretinopathy: A Retrospective Case Series.

Introduction: The present study aimed to describe a case series of patients in which a cohesive ophthalmic viscous device (OVD) was used to viscodissect and posteriorly displace the retina in cases of total retinal detachment complicated by proliferative vitreoretinopathy, operated with minimally invasive pars plana vitrectomy. Case Presentations: Three patients with a mean age of 67 years were included in the present study. One eye was aphakic, while the others were pseudophakic. OVD injection was performed through the limbus in the aphakic eye and via pars plana in the pseudophakic eyes. In all cases, the OVD injection led to a posterior displacement of the detached retina with a smooth dissection. No complications related to the surgery were observed. At the last follow-up visit, the retina was attached in all cases, with an improvement in visual acuity. Conclusion: To conclude, the injection of a cohesive OVD anterior to the detached retina allowed to posteriorize and viscodissect to some extent the retina, facilitating the implant of trocars.

Epiretinal implant of human amniotic membrane to treat highly myopic macular hole retinal detachments: A novel surgical technique.

PURPOSE: To describe a new surgical technique involving the use of a human amniotic membrane (hAM) epiretinal patch to treat a primary macular hole retinal detachment (MHRD) in a highly myopic patient. METHODS: A 60 years old highly myopic man was referred to our clinic with a diagnosis of MHRD in his right eye. The patient was pseudophakic, with a visual acuity of counting fingers at the baseline evaluation. Pars plana vitrectomy was performed, a small retinotomy was created at the inner margin of the staphyloma, and membrane blue dual was used to obtain an adequate peeling of the inner limiting membrane. Then, a 1.5 mm diameter circular hAM patch was obtained and positioned over the macular hole with the chorion layer settled over the retina. After a complete fluid-air exchange, 20% sulfur hexafluoride gas was used as endotamponade, and the patient was asked to remain face down for three days. RESULTS: Four weeks after surgery, optical coherence tomography (OCT) scan showed the hAM patch, visualized as a distinct hyperreflective layer well integrated with the retina. Nine months after surgery, the macular hole was closed, the retina reattached, the hAM patch was adherent to the retina, and the patient presented a best-corrected visual acuity improved to 0.7 logMar. No postoperative adverse events were registered during the follow-up. CONCLUSIONS: Epiretinal hAM implant could represent a novel surgical technique, feasible and easier compared to other current techniques used to treat MHRD in highly myopic patients.

A parafoveal retinal cones analysis using adaptive-optics retinal camera in patients with primary open angle glaucoma.

OBJECTIVES: To study the density, spacing, and regularity of retinal cone photoreceptors using an Adaptive Optics (AO) retinal camera (Rtx1TM, Imagine Eyes, Orsay, France) in patients with Primary Open Angle Glaucoma (POAG) and to compare the outcomes with those of healthy age-matched control subjects. METHODS: The study included 43 eyes with POAG and 31 eyes of normal subjects. POAG patients were divided into three groups according to the severity of the visual field defect. The AO Rtx1TM was used to obtain images of the parafoveal cone mosaic to calculate cone values. Analysis was performed at two and four degrees of eccentricity from the fovea along the four meridians (nasal, temporal, superior, inferior). RESULTS: In POAG eyes, the mean ± standard deviation (SD) cone density at 2° considering all meridians was significantly lower than in normal controls (23,058.6 ± 3532.0 cones/mm2, and 25,511.7 ± 3157.5 cones/mm2, respectively; p = 0.003). Cone spacing was 7.3 ± 0.5 µm in POAG and 7.0 ± 0.4 µm in normal controls (p = 0.005), and cone regularity was 90.5 ± 4.9% and 93.5 ± 1.9% in POAG and normal controls, respectively (p < 0.001). At 4° similar trends were observed. However, no significant differences were found among patients with different severity of POAG (p > 0.05). CONCLUSIONS: Using AO Rtx1TM, significant differences in retinal photoreceptors mosaic pattern were found between POAG eyes and age-matched controls, indicating a reduction in photoreceptors in POAG. No significant differences in retinal photoreceptor values were found among the three POAG groups.

Assessment of optical coherence tomography biomarkers in patients with non-neovascular age-related macular degeneration (AMD) converting to exudative AMD according to the status of the fellow eye.

OBJECTIVES: To compare optical coherence tomography (OCT) biomarkers in eyes converting from non-neovascular (nnAMD) to exudative age-related macular degeneration (eAMD) based on the status of fellow eye. METHODS: Retrospective analysis of one year of pre-conversion data of fellow eyes of patients with nnAMD and eAMD which converted to eAMD, defined as converting eyes (CE) with fellow nnAMD and CE with fellow eAMD respectively. Demographics, best corrected visual acuity (BCVA), and OCT biomarkers including drusen type, iRORA/cRORA, subfoveal ellipsoid zone (SFEZ) disruption, central macular thickness (CMT), subfoveal choroidal thickness (SFCT), Haller vascular thickness (HVT) were evaluated. Chi-square and t-tests were employed, confidence interval of 95% and p < 0.05. RESULTS: 72 eyes of 72 patients were included: 31 CE with fellow nnAMD and 41 CE with fellow eAMD. Mean age was 81.8 ± 9.9 years, with 62.5% females. Subfoveal iRORA was more frequent in CE with fellow nnAMD (26%) compared to CE with fellow eAMD (6%) 44 weeks before conversion (p = 0.058). SFCT and HVT were higher in CE with fellow nnAMD compared to CE with fellow eAMD 19 weeks prior to conversion (213 ± 82 vs. 174 ± 63 µm, p = 0.052; 121 ± 44 vs. 104 ± 50 µm, p = 0.084 respectively). BCVA was significantly higher in CE with fellow eAMD compared to CE with fellow nnAMD every time frame (p < 0.05). CONCLUSIONS: Although subtle distinctions, no significant differences were observed between the groups. Further research is needed to understand the influence of one eye's status on progression from nnAMD to eAMD in fellow eye.

Long-term surgical outcome and impact on daily life activities of strabismus surgery in thyroid-associated ophthalmopathy with and without previous orbital decompression.

BACKGROUNDS: To report the long-term surgical outcomes and the impact on daily life activities of strabismus surgery in patients with Thyroid Associated Orbitopathy (TAO) with and without previous orbital decompression. METHODS: Patients who underwent strabismus surgery for TAO were retrospectively reviewed. The primary outcome was to evaluate the influence of orbital decompression on the outcomes of TAO related strabismus surgery. Surgical success was defined by the resolution of diplopia and a post-operative deviation < 10 prism diopters (PD). The secondary outcomes were the clinical features, surgical approaches, and impact on daily life activities. RESULTS: A total of 45 patients were included in the study. The decompression surgery group (DS) included 21 patients (46.7%), whereas the non-decompression surgery group (NDS) patients were 24 (53.3%). The mean follow-up time from the last strabismus surgery was 2,8 years (range 8-200 months). Successful surgical outcome was achieved in 57,1% of patients in the DS, and 75% of patients in the NDS (p = 0,226). DS patients required almost twice the number of surgical interventions for strabismus compared to the NDS (1,95 vs. 1,16 respectively, p = 0,006), a higher number of extraocular muscles recessed in the first surgery (2,67 vs. 1,08 respectively, p < 0.001), and a lower rate of unidirectional surgery compared to NDS (23% vs. 95%, p < 0,001). At the pre-operative assessment, 71.4% of DS patients had eso-hypotropia, while no patients had this type of strabismus in the NDS group (p < 0.001). On the other hand, the hypotropia rate was 79.2% in NDS patients and only 4.8% in DS patients (p < 0.001). Moreover, 21,8% of NDS patients used prism lenses in daily life activities, compared to 42.9% of patients that used prism lenses to reduce the impairment in their daily life activities (p = 0.016). CONCLUSIONS: The results of our study showed that DS patients required almost twice the number of strabismus surgical procedures, a higher number of extraocular muscles recessed in the first surgery, and an increased need for prism lenses to correct the residual deviation compared to the NDS, but with similar long-term surgical outcomes.

Retrolental cohesive ophthalmic viscoelastic injection for severe subluxated cataracts: a prospective study.

BACKGROUND: To assess anatomical and functional outcomes of retrolental cohesive ophthalmic viscoelastic injection ("Viscolift technique") in patients with severely subluxated cataracts. METHODS: In the present prospective study, we included patients older than 18 years with severely subluxated cataracts and phacodonesis. Full medical history was obtained at the baseline ophthalmological assessment. A single 25-gauge valved trocar was inserted 4 mm from the limbus and a 27G angled cannula was introduced through the trocar into the retrolental space, while cohesive viscoelastic was progressively injected, in order to center and elevate the cataract to facilitate capsulorhexis. After complete phacoemulsification, a 3-piece intraocular lens (IOL) with a scleral fixated Cionni ring or FIL-SSF scleral fixated IOL was implanted. Patients follow-up interval was 6 months after surgery. RESULTS: Thirteen eyes of 13 patients were enrolled in the study, mean age was 61.5 ± 9.4 years and 53.8% were females. The "Viscolift technique" resulted in centered and more stable cataracts in all cases (100%). After complete phacoemulsification, 61.5% of patients were implanted with a 3-piece IOL with Cionni ring, and 38.5% with a FIL-SSF scleral fixated IOL after complete 25G vitrectomy. Mean BCVA improved from 0.5 ± 0.1 LogMar (20/63 Snellen) to 0.1 ± 0.1 LogMar (20/25 Snellen) (p < 0.001) at the last follow-up. No major complications were noted. CONCLUSIONS: The "Viscolift technique" proved to be a safe and effective surgical approach for recentering and elevating subluxated cataracts, thus allowing the surgeon to perform an easier and better-centered capsulorhexis.

Choroidal biomarkers in age-related macular degeneration.

Age-related macular degeneration (AMD) is the leading cause of central visual impairment in the elderly. The exact pathophysiological mechanisms for AMD remain uncertain. Several studies suggest that choroidal abnormalities and alterations are critical in AMD progression. The transition from manual to automated segmentation and binarization techniques has resulted in accurate and precise measurements of different choroidal parameters. These qualitative and quantitative parameters, known as choroidal imaging biomarkers, have advanced from basic vertical subfoveal choroidal thickness to more intricate 3-dimensional choroidal reconstruction methods in the last decade. Therefore, a comprehensive evaluation of choroidal metrics may investigate valuable insights into AMD, potentially guiding the future development of customized therapeutic strategies and personalized patient care in AMD management. We describe the role of different choroidal biomarkers in evaluating patients with AMD and their contribution to management.

Geographic atrophy progression secondary to age-related macular degeneration: Five years of follow-up.

PURPOSE: To study the progression of geographic atrophy (GA) secondary to age-related macular degeneration over a five-year follow-up. METHODS: Eyes with GA included to assess demographic data, yearly optical coherence tomography (OCT) findings and the GA growth rate on infra-red (IR) images. RESULTS: A total of 41 eyes of 29 patients were included with a mean age of 81.76 ± 6.37 at baseline, and 65.51% were females. Over five years, there was a significant increase in the mean GA area from 8.44 ± 8.98 mm² to 13.32 ± 10.07 mm² (P < 0.001), with an annual growth rate of 1.14 ± 0.78 mm². The annual growth rates in females were slightly higher compared to males (1.29 ± 0.89 mm2 vs 0.96 ± 0.49 mm2, p = 0.569), and in smokers was slightly higher than non-smokers (1.35 ± 0.85 mm2 vs 0.94 ± 0.66 mm2, p = 0.100). Larger GA areas at the baseline showed higher GA progression in mm2 per year (P = 0.04). Smaller GA areas and fovea-spared GA at the baseline exhibited a larger percentage increase (P < 0.001 and P = 0.015, respectively). There was a lower GA progression rate in eyes with outer retinal tubulations (ORT) (P = 0.027), yet no significant correlation was found between GA progression and other OCT features. CONCLUSIONS: Smaller, fovea-sparing GA eyes experienced a more substantial proportional increase over five years. Also, The presence of ORT was associated with a slower rate of GA progression. Additionally, we observed a trend of faster GA growth in smokers and female genders.

AAPOS Adult Strabismus Committee's Report on the Status of Adult Strabismus Telemedicine.

PURPOSE: To evaluate the utility of telemedicine in the treatment of adult patients with strabismus. METHODS: A 27-question online survey was sent to ophthalmologists of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Adult Strabismus Committee. The questionnaire focused on the frequency of telemedicine utilization, the benefits in the diagnosis, follow-up, and treatment of adult strabismus, and barriers of current forms of remote patient visits. RESULTS: The survey was completed by 16 of 19 members of the committee. Most respondents (93.8%) reported 0 to 2 years of experience with telemedicine. Telemedicine was found to be useful for initial screening and follow-up of established patients with adult strabismus, mainly to reduce wait time for a subspecialist visit (46.7%). A successful telemedicine visit could be completed with a basic laptop (73.3%) or a camera (26.7%) or could be assisted by an orthoptist. Most participants agreed that common forms of adult strabismus (cranial nerve palsies, sagging eye syndrome, myogenic strabismus, and thyroid ophthalmopathy) could be examined via webcam. It was easier to analyze horizontal than vertical strabismus. Among the paralytic forms, sixth nerve palsy was the easiest one to assess. Latent forms of strabismus can be partially diagnosed and evaluated using telemedicine, but half of the respondents underlined the importance of in-person examinations in these cases. Sixty-nine percent believed that telemedicine could be a low-cost and time-efficient health service solution. CONCLUSIONS: Most members of the AAPOS Adult Strabismus Committee consider telemedicine to be a useful supplement to the current adult strabismus practice. [J Pediatr Ophthalmol Strabismus. 2023;60(6):386-389.].

Choroidal morphology and microvascular structure in eyes of patients with idiopathic normal pressure hydrocephalus before and after ventriculo-peritoneal shunt surgery.

The present study aims to investigate the choroidal morphology and microvascular structure in eyes of patients with idiopathic normal pressure hydrocephalus (iNPH) compared with the eyes of healthy age-matched individuals, and to assess the choroidal structure in eyes of iNPH patients before and after shunt surgery using Optical Coherence Tomography (OCT). The primary objective was to assess the choroidal morphology in eyes of iNPH patients before and after ventriculo-peritoneal (VP) surgery compared to age and sex-matched healthy individuals. The secondary objective was to compare the choroidal morphology of iNPH patients before and after a mean of 56 days from shunt surgery. Eighteen consecutive patients diagnosed with iNPH and 18 healthy controls were prospectively recruited between November 2021 and October 2022. Spectral-domain optical coherence tomography (SD-OCT) with enhanced depth imaging (EDI) was conducted before and within 4 months after shunt surgery. Images were binarized using the ImageJ software, and the choroidal vascular index (CVI) was calculated. Sub-foveal choroidal thickness (SFCT), total choroidal area (TCA), luminal choroidal area (LCA), and stromal choroidal area (SCA) were significantly increased in iNPH patients before surgery compared to the control group (p < 0.05). SFCT, TCA, and SCA were significantly increased in iNPH patients after surgery compared to the control group (p < 0.05). There were no differences in the CVI between iNPH patients and controls. No statistical differences in the choroidal structure were observed before and after VP shunt surgery (p > 0.05). In conclusion, the choroid was thicker in iNPH patients before and after VP shunt compared to age-matched healthy individuals. However, there were no difference in the choroidal microstructure in the eyes of iNPH patients before and after a mean of 3 months from VP shunt surgery.

INPH and parkinsonism: A positive shunt response with a negative tap test.

Introduction: The aim of this study was to compare clinical and functional performances of idiopathic normal pressure hydrocephalus (INPH) patients with and without parkinsonism at the initial evaluation, 72 h after the cerebrospinal fluid tap test (CSF TT), and 6 months after ventriculoperitoneal shunt (VPS) surgery. Materials and methods: This is an observational prospective study on patients with INPH who underwent VPS. Patients were classified into INPH with parkinsonism (INPH-P+) and without parkinsonism (INPH-P-). We used the time up and go (TUG) test, Tinetti Performance-Oriented Mobility Assessment (POMA) test, INPH grading scale (INHPGS), and modified Rankin scale (mRS) at baseline, 72 h after CSF TT, and 6 months after VPS surgery. Results: A total of 64 patients with probable INPH were included, 12 patients with INPH-P+ and 52 controls with INPH-P-. Patients with INPH showed significant improvement in all clinical and neurological parameters after VPS including TUG, Tinetti POMA, INPHGS, and mRS (p < 0.001) with the exception of mRS where there was no significant change 72 h after CSF TT compared to baseline for patients with INPH (p = 0.182). Patients with INPH-P+ performed significantly worse than patients with INPH-P- on Tinetti POMA and mRS at baseline, at 72 h post-CSF TT, and at 6 months post-VPS with INPHGS being worst at 72 h post-CSF TT. There was no difference between patients with INPH-P+ and patients with INPH-P- for TUG at baseline (p = 0.270), at 72 h post-CSF TT (p = 0.487), and at 6 months post-VPS (p = 0.182). Patients with INPH-P+ did not show any change in any of the parameters at 72 h post-CSF TT compared to baseline; however, there was a trend toward improvement on TUG (p = 0.058), Tinetti gait (p = 0.062), and Tinetti total (p = 0.067). INPH-P+ significantly improved in all parameters 6 months post-VPS compared to baseline except for mRS (p = 0.124). Patients with INPH-P- significantly improved in all parameters at 72 h post-CSF TT and at 6 months post-VPS compared to baseline, respectively, except on mRS 72 h after CSF TT (p = 0.299). Conclusion: Patients with INPH and parkinsonism overall do worse than patients without parkinsonism. An unsatisfying response to the CSF tap test in INPH patients with parkinsonism should not be used as an exclusion criterion from VPS surgery since patients with and without parkinsonism showed significant improvement post-VPS.

Epidemiology, clinical features, and surgical outcomes of acute acquired concomitant esotropia associated with myopia.

PURPOSE: To analyze epidemiology, clinical features, and surgical outcomes of type III acute acquired concomitant esotropia (Bielschowsky esotropia (BE)). METHODS: The medical charts of patients diagnosed with acquired concomitant esotropia between 2013 and 2021 were reviewed. Assessed data were age, gender, age at diplopia onset, age at the diagnosis, refraction, visual acuity, neuroimaging, diplopia onset, angle of deviation, stereopsis, surgical procedure, amount of surgery, and relapse of diplopia after surgery. Moreover, we investigated the correlation between the use of electronic devices and the onset of diplopia. RESULTS: One hundred seventeen patients (mean age 35.07 ± 15.81 years) were included in the study. The mean delay to the diagnosis was 3.29 ± 3.62 years. Myopia range was 0 to 17 diopters spherical equivalent. 66,3% spent more than 4 hours a day using laptops, tablets, or smartphones at the onset of diplopia, and 90,6% presented a subacute onset. None showed neurologic signs or symptoms. Patients who underwent surgery were ninety-three, with a rate of surgical success of 93.6%, and a relapse rate of 17.2%. A negative correlation resulted between pre-operative deviation and age at diagnosis (ρ = -0.261; p<0.05), whereas factors associated with surgical failure were older age at diplopia onset (p = 0.042) and longer delay between onset and diagnosis (p = 0.002). CONCLUSION: We registered an outstanding increase in prevalence of BE, which could be related to the exponential increase in the use of electronic devices for professional, educational, and recreational purposes. A prompt diagnosis and an augmented dose of surgery allows good motor and sensory results.

Effects of Photo-Biomodulation in Stargardt Disease.

PURPOSE: Stargardt disease (STGD1) is the most common hereditary macular degeneration and currently no treatments have been approved to interrupt the progression of the disease. The aim of this study was to evaluate the efficacy of photo-biomodulation in patients with Stargardt disease 1 year after treatment, considering as primary outcomes improvements in best corrected visual acuity (BCVA), microperimetry, and pattern electroretinography (PERG) amplitude. MATERIALS AND METHODS: Ninety eyes of 45 patients with a diagnosis of Stargardt disease stage 1 were prospectively recruited at the University of Bologna. Selected patients were treated with photo-biomodulation therapy for 1 year for 10 minutes a day, twice a day, and 5 days per week for 12 months. A light emitting diode (LED) of 10 Hz and wavelength 650 nm was used. BCVA and microperimetry were assessed before treatment and 1 year after photo-biomodulation, whereas PERG was assessed at baseline, 1, 3, 6, and 12 months after treatment. RESULTS: BCVA improved from 0.7 [interquartile range (IQR)=0.6-0.9)] to 0.4 (IQR=0.2-0.5)] after treatment (95% CI=-0.3, -0.35; p=<0.001) and PERG negative wave at 35 ms (N35)-positive wave at 50 ms (P50) amplitude improved from 0.9 (IQR=0.74-1.21) to 2.12 (95% CI=1.11, 1.28; p<0.001). MP-1 Microperimetry improved from 26.5% (IQR=16.75-40) of median preferred retinal loci (PRL) within an area of 2° of diameter to 38% (IQR=29-50.25; 95% CI=10.50, 14.50; p=<0.001); on the other hand, PRL within 4° of diameter raised from 72% (IQR=51.5-80) to 80% (IQR=76-87) after photo-biomodulation (95% CI=4.50, 7.50; p<0.001). Also, patients with an improvement of more than 1.205 PERG N35-P50 ratio amplitude at 3 months and more than 1.29 at 6 months tended to present an improvement of more than 0.2 logMar in BCVA at 12 months (p=0.28, AUC=0.630; p=0.30, AUC=0.636). CONCLUSION: BCVA, PERG, and MP-1 significantly improved 1 year after treatment. Also, improvement of PERG N35-P50 amplitude at 3 and 6 months was correlated to BCVA improvement at 1 year, suggesting that PERG could be useful in predicting visual outcome after photo-biomodulation.

Chronic Central Serous Chorioretinopathy with Pigment Epithelium Detachment Treated with Sildenafil: A Case Report.

Central serous chorioretinopathy (CSCR) is a retinal disease that may be complicated by the development of serous retinal pigment epithelial detachment (PED). The exact molecular mechanisms of CSCR have remained uncertain as well as there is no effective medical therapy. Herein, we describe a case of a 43-year-old male suffering from chronic CSCR with PED and visual acuity reduction (20/40) that showed improvement in visual acuity (20/25) and metamorphopsia 2 weeks after daily intake of 20 mg sildenafil tablets. Optical coherence tomography (OCT) scan showed resolution of PED with residual degeneration of the photoreceptor inner and outer segment layer and retinal pigmented epithelium. The patient continued treatment with sildenafil 20 mg for 2 months. Six months after the discontinuation of therapy, visual acuity was maintained, with absence of PED at OCT. Our case supports the hypothesis that phosphodiesterase type 5 (PDE-5) inhibitors may be an alternative in the treatment of patients with CSCR, alone or combined with other medications.